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Impact of Sleep on Arrhythmogenesis by Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol Volume 2(4):450-459 August 1, 2009 Copyright © American Heart Association, Inc. All rights reserved. Figure 1. A, Hourly incidence of sudden cardiac death (SCD) onset between midnight and 5:59 am from 12 studies enrolling 1981 patients.2 B, Hourly incidence of automatic implantable cardioverter-defibrillator (AICD) discharge between midnight and 5:59 am from 7 studies enrolling 1197 patients. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 2. Importance of monitoring nocturnal oxygen saturation following myocardial infarction.27 Nonsustained ventricular tachycardia (lower panel) and hypoxemia measured by pulse oximetry (upper panel) occurred simultaneously on the third night after infarction. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 3. Arrhythmia prevalence (%) according to sleep-disordered breathing status.28 Shaded bars, sleep-disordered breathing; open bars, non–sleep-disordered breathing. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 4. Recordings of sympathetic nerve activity (SNA), respiration (RESP), and intra-arterial blood pressure (BP) in the same subject when awake, with obstructive sleep apnea during REM sleep, and with elimination of obstructive apnea by continuous positive airway pressure (CPAP) therapy during REM sleep.31 SNA was very high during wakefulness but increased even further secondary to obstructive apnea during REM. BP increased from 130/65 mm Hg when awake to 256/110 mm Hg at the end of apnea. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 5. Survival of patients with heart failure, with or without CSA after accounting for all other confounders.48 AHI, Apnea-hypopnea index. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 6. Freedom from cardiac mortality based on modified moving average analysis of T-wave alternans (TD-TWA) from 24-hour ambulatory ECGs in ischemic (A) and nonischemic (B) study subgroups.52 Reprinted with permission from Heart Rhythm Society. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 7. Representative rhythm strip (left) and QRS-aligned superimposed modified moving average waveforms (right) for the maximum T-wave alternans (≥65 μV) in lead V3 from a patient with heart failure who was enrolled in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study.51 Note the lack of separation between the superimposed beats in the isoelectric PQRS complex, indicating the low level of noise. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 8. Heart rate trend from an ambulatory ECG (AECG) recording showing a normal circadian rhythm with a sleep-induced decrease in heart rate (A) as compared with a nocturnal increase in heart rate caused by paroxysmal atrial fibrillation at the onset of sleep and a drop in heart rate after awakening due to spontaneous conversion to sinus rhythm (B).65 The ECG (below) documents atrial fibrillation during the sleep period. Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved. Figure 9. Incidence of atrial fibrillation (AF), based on presence or absence of OSA.67 Cumulative frequency curves for incident AF for subjects <65 years of age with and without OSA during an average 4.7 years of follow-up (P=0.002). Richard L. Verrier, and Mark E. Josephson Circ Arrhythm Electrophysiol. 2009;2:450-459 Copyright © American Heart Association, Inc. All rights reserved.
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